Dropping Aspirin Cuts Bleeding in LVAD Patients

PHILADELPHIA, Pennsylvania — Aspirin may not be necessary or beneficial in patients with advanced heart failure who get a left ventricular assist device (LVAD), particularly if it's a newer device that does not use the centrifugal- or continuous-flow pump technology of conventional LVADs, new randomized results suggest.

"We've always thought that somehow aspirin prevents stroke and prevents clotting and that it's anti-inflammatory, and what we found in ARIES was the exact opposite," said Mandeep Mehra, MD, of Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School in Boston, Massachusetts, who reported results of the ARIES-HM3 trial of the HeartMate 3 LVAD, a device that uses a fully magnetically levitated rotor to maintain blood flow.

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ARIES-HM3 randomly assigned 589 patients who received the HeartMate 3 device to vitamin K therapy with aspirin or to placebo. Mehra said it was the first international trial to conclusively evaluate medical therapy in patients who get an LVAD.

Unexpected Findings

"To be honest with you, we set this up as a safety study to see if we could eliminate aspirin," Mehra said in an interview. "We didn't expect that the bleeding rates would decrease by 34% and that gastrointestinal (GI) bleeding in particular would decrease by 40%. We didn't expect that it would nearly halve the days spent in the hospital, and we didn't expect that the cost of care would decrease by 40%."

Mehra reported the results at the American Heart Association (AHA) Scientific Sessions 2023. They were published simultaneously online in JAMA.

The researchers found that 74% of patients in the placebo group met the primary endpoint of being alive and not having any hemocompatibility events at 12 months vs 68% of the aspirin patients. The rate of nonsurgical bleeding events was 30% in the placebo group vs 42.4% in the aspirin patients. The rates of GI bleeding were 13% and 21.6% in the respective groups.

In his talk, Mehra noted the placebo group spent 47% fewer days in the hospital for bleeding, with hospitalization costs 41% lower than the aspirin group.

"We are very quick to throw things as deemed medical therapy at patients and this study outcome should give us pause that not everything we do may be right, and that we need to start building a stronger evidence base in medical therapy for what we do with patients that are on device support," Mehra said.

Shift of Focus to Therapy

The study's focus on aspirin therapy may be as significant as its evaluation of the HeartMate 3 LVAD, discussant Eric David Adler, MD, a cardiologist and section head of heart transplant at the University of California San Diego, said in an interview.

Dr Eric David Adler

"We focus so much on the device," he said. "It's like a set-it-and-forget-it kind of thing and we're surprised that we see complications because we haven't put a lot of effort into the medical therapy component."

But he credited this study for doing just that, adding that it can serve as a model for future studies of LVADs, although such studies can face hurdles. "These studies are not trivial to accomplish," he said. "Placebo medical therapy studies are very expensive, but I think this is a mandate for doing more studies. This is just the tip of the iceberg."

Additionally, evaluating hospital stays in LVAD studies "is a really important endpoint," Adler said.

"For me, one of the key things that we don't think about enough is that lowering days in the hospital is a really big deal," he said. "No one wants to spend time in the hospital, so anything we can do to lower the amount of hospital days is real impactful."

Abbott funded and sponsored the ARIES-HM3 trial. Mehra disclosed relationships with Abbott, Moderna, Natera, Transmedics, Paragonix, NupulseCV, FineHeart, and Leviticus. Adler has disclosed no relevant financial relationships.

American Heart Association (AHA) Scientific Sessions 2023: LBS Session 03: ARIES HM3: Avoidance of aspirin with left ventricular assist devices in advanced heart failure: primary results of the international, double-blind, placebo-controlled ARIES HM3 clinical trial. Presented November 11, 2023.

J Am Med Assoc. Published online November 11, 2023. Full text

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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